Aavd spring 2018 derm dialogue 050118 issuu

DERM DIALOGUE Editor: Norma White-Weithers, MS, DVM, DACVD Veterinary Allergy & Dematology Consultant, Baldwin, NY 11510 Work: 646-329-4719 | Fax: 631-694-3401 | E-mail: nweithers@yahoo.com Assistant Editor: Tim Strauss, DVM Frederick,CO 80516 | E-mail: drtim@comcast.net

SPRING 2018

FROM THE PRESIDENT Dear Colleagues, I hope to see many of you at the upcoming NAVDF meeting in gorgeous Maui from May 1st to the 5th. We will have an extended meeting with 2 half days in the program on Friday and Saturday to permit people to sightsee, put their toes in the sand or the surf, or just relax by a pool. There are so many things to do in Maui, there really is something for everyone.

Dr. Outerbridge

Please include in your plans to attend the AAVD members business meeting on Wednesday, May 2nd from 5:45 pm to 6:45 pm in the Lokelani Ballroom at the Marriott Wailea Beach Resort. This will occur at the end of the first full day of the meeting, and we will have liquid refreshments in case people are needing a drink.

While at the meeting, please thank your colleagues on the NAVDF Program Committee and Organizing Committee who have worked hard to plan this meeting. They are all busy individuals who volunteer their time to make this meeting a success. Also, be sure to say hello and thank our wonderful professional staff from PAMED, in particular Libby Dietrich, Jill Senior and Kim Whetsell. They work throughout the year on behalf of the AAVD and NAVDF. They are assisted by the incomparable Alexis Borich, ACVD’s ___ in helping to organize the NAVDF. Be sure to check out navdf.org for more information about the program and what promises to be another exceptional meeting in a beautiful part of the world.

Our own AAVD.org website has been redesigned and the new and improved website can now be accessed from your mobile phone or tablet. There will be a new secure member login portion of the site that will allow you to pay dues online and update or modify your contact information. For those members that obtain their subscription to Veterinary Dermatology through the AAVD, you will still be able to access your subscription through the website. The new format of the website is going to allow us to develop an online interactive community in the future. If you have colleagues, or work with technicians or students who have a passion for dermatology, invite them to become AAVD members. The new website will have new member forms that can be completed online. Joining AAVD has never been easier and we welcome all who share our commitment to the specialty of veterinary dermatology.

Aloha and mahalo,

Catherine Outerbridge, DVM, DACVD, DACVIM AAVD President

ROUNDTABLE SUMMARIES Cytopoint: Experiences and Questions Moderator: Kimberly Coyner. DVM | Secretary: Emily Rothstein. DVM Attendees: 19 Private dermatology specialty practice: 13 Private practice: 4 University: 0 Other: 2 veterinary dermatologists from Zoetis This round table was designed to discuss multiple specific questions (which were emailed to participants prior to the meeting) about our collective Cytopoint experiences in clinical practice.

1. Number of dogs you have treated with Cytopoint/CADI? • Kim Coyner : between 10/2015-12/31/16: 244 dogs/847 injections; 3-4 /week average • Mary Schick: >234 dogs • Karen Kuhl: 400, 3-4/week • Others were similar to lower numbers Further comments included a discussion of the need for Zoetis and dermatologists to educate private practitioners on this new drug, mechanism of action, indications and contraindications (such as administration to cats), and that the roll out of this drug has not seemed to have had as much fanfare as Apoquel did in the past. Some private practitioners were unaware of the drug or its appropriate use, or were cautious to use it after having issues with Apoquel supply in the past; Andy Hillier (Zoetis) stated that Zoetis has been disseminating information about Cytopoint at lectures and meetings, as well as online resources for veterinarians (https://www.zoetisus.com/products/dogs/cytopoint/) and pet owners (http://www.cytopoint4dogs.com/).

2. % patients which were treatment successes? (injection was helpful for at least 4 weeks) • Kim Coyner: 151 dogs (62%) were itch free at least 4 weeks, 67 dogs (27%) were not itch free for at least 4 weeks, and 26 dogs (11%) had no follow up to determine efficacy. Of the 151 dogs considered treatment successes: 64% dogs had pruritus control for 4 weeks, 9% for 6 weeks, 10% for 8 weeks, and 17% > 8 weeks (usually seasonal itch flares or dogs that responded to hypoallergenic diets).

• Sarah Columbini: 70% of her patients are itch free for 3 weeks-3 months post Cytopoint injection.

• Emily Rothstein: Has 3 German shepherd patients which are itch free for several months after Cytopoint.

Further comments included that most owners noted some itch 2-3 days just before the 4-week point, stimulating the question of whether Cytopoint can be used more frequently, i.e. every 3 weeks? Andy Hillier stated that there is no data to suggest problems with 3 weeks administration frequency but also no data to document long term safety of this administration, though prior safety studies in laboratory dogs demonstrated safely of Cytopoint at 5X the label dose.

3. The question was then asked how many participants were administering Cytopoint more frequently than every 4 weeks?

• A few participants were comfortable using it q 3 weeks.

• Others used it as labelled q 4 weeks and instructed owners to administer Apoquel if needed to control itch until the next Cytopoint injection could be given.

• Two Canadian attendees administer Cytopoint at the 4 week label frequency as the drug is still under conditional licensure in Canada.

The question was then raised about if Cytopoint becomes more effective with subsequent dosing?

• Andy Hillier stated that there have been reports that Cytopoint is more effective in some patients after the second or third injection.

• Mary Schick concurred she had seen this occur.

• Most participants did not have that experience.

4. % of cases which Cytopoint injections initially were very helpful then stopped working or caused side effects and had to be discontinued?

• Kim Coyner: 5 dogs (2%) were initially helped for the first 1-2 Cytopoint injections then subsequent injections did not help and 2 dogs (0.8%) had side effects such as lethargy and GI upset severe enough to cause discontinuation.

• Karen Kuhl: 5-10% (10 of 400) worked less and less each shot given until failed altogether (no time given).

• Two other participants experienced decreased efficacy after 2nd or 3rd injection.

• Andy Hiller discussed reasons for Cytopoint treatment failure including other flare factors (infections, parasites; all agreed this was a common reason for pruritus flares in atopic dogs but that as dermatologists we are capable of identifying

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these flare factors, so unlikely to be the case in our patients), and anti-drug-antibodies (occurred in 2.5% of dogs in one Cytopoint clinical trial), but the latter should not be a slow but abrupt decline in efficacy.

5. Participants were then asked if they were using Cytopoint for symptomatic relief when infection was present causing severe pruritus/while infection was treated?

• Reaction was mixed.

• Some participants used Cytopoint regardless of infection and felt it worked well.

• Others waited until infection was controlled (and used a short course of steroids or Apoquel if needed, stopping well before antibiotics were finished) prior using Cytopoint for the concern that if it did not work due to infection clients would be reluctant to try it again in the future.

The question was raised of how many patients are referred specifically for Cytopoint injections, not many had this experience. The discussion then expanded to the need for a definitive diagnosis of atopy prior to use of Cytopoint- Andy Hillier said Zoetis has a 4 pronged algorithm discussing the diagnostic and therapeutic approach to a pruritic dog. This algorithm is a Cytopoint iDetailer is used by Zoetis reps when they talk to veterinarians and is not approved for external use or general distribution.

6. What side effects have you seen?

• Kim Coyner: pain on injection 1 dog, vomiting 7 dogs, diarrhea 2, (total GI upset: 9 dogs/3.7%); anorexia, lethargy 4 dogs/1.6%, increased itch 4 dogs/1.6%.

• Sarah Columbini: has seen GI side effects including vomiting or diarrhea occurring 1 day to 3 weeks post injection and had one patient with consistently repeatable lethargy and nasal congestion 2-3 d after injection.

• Vincent Defalque: requires patients to wait 15 min in office after each injection but has seen no adverse reactions. (Andy Hillier commented that patients were required to wait 30 min in the Cytopoint clinical trial and no allergic reactions occurred).

• One participant from Canada had one patient with diarrhea post Cytopoint which is controllable with Tylosin and another patient which developed angioedema after the first Cytopoint injection, the first time immediately and the second injection angioedema developed the following morning.

• Karen Kuhl: had 2 patients that developed hives 8-10 days after receiving Cytopoint, and had no prior history of hives, however other allergenic causes were possible since the episodes occurred in the spring; 1 of these dogs had a good response/control of pruritus, the other patient (a veterinary technician’s dog) developed subsequent hairloss and the injection helped for only 2 weeks and so was not repeated.

• Mary Schick: had a few patients who were lethargic for 2-3 hours after Cytopoint injections, but may have just been exhausted from itching and finally able to rest; she felt the lethargic dogs were often the best Cytopoint responders.

• Three other participants had patients with pain on injection, often in small dogs, but one participant had 2 large dogs in one day with pain on injection that had not occurred on prior injections, this was reported to Zoetis in case of a drug lot issue.

This then led to a discussion of the difficulty some US participants had in reporting possible adverse events to Zoetis, that in some cases the Zoetis representative seemed to minimize or deny the possibility of a relationship between the drug and suspected adverse event, or list the adverse events noted in the clinical trials (which is unnecessary to relate to diplomates who have already read these studies or have been the participants in the clinical trials); the statement was made that it would solve the issue if dermatologists could have a dedicated report line. Round table participants from Canada related that they never experienced these issues when calling Zoetis and could even report events online.

The discussion then shifted to the question about possible side effects of long term IL-31 inhibition?

• Andy Hillier related that in safety studies of Cytopoint given at 10mg/kg for 7 treatments, no adverse effects occurred, and that redundant cytokines could be expected to take over any maintenance functions.

• Additionally, IL-31 is known to have a role in other inflammatory diseases (increased IL 31 has been found in asthma and IBD), but has not been found to have an essential role in normal immune function.

• (Moderator note: IL-31 receptors are found on canine keratinocytes, monocytes, and dorsal root ganglia where cell bodies of sensory neurons reside; in human and mouse studies IL-31 receptors have also been found on eosinophils, mast cells, bronchial epithelia, colonic subepithelial myofibroblasts, spleen, bone marrow, ovary, and testes).

7. Have you had cases in which Apoquel was not helpful but Cytopoint was?

• Kim Coyner: 6 dogs (2.5%) • Kinga Gortel : had a few dogs.

• One participant noted that Cytopoint was helpful in half of her Apoquel failures.

• Patrick Mckeever: noted he has had several severe pododermatitis cases which did not respond to either Apoquel or Cytopoint.

8. Have you had cases in which Cytopoint was not helpful but Apoquel was?

• Kim Coyner: 19 dogs (8%).

• Several other participants had cases as well.

The discussion of the different mechanisms of action of Cytopoint vs/ Apoquel (IL-31 sole inhibition vs. JAK enzyme inhibition) followed to explain the different effects in some dogs. Michele Rosenbaum (Zoetis) stated that in some dogs there may be polymorphisms in the JAK enzymes such that Apoquel cannot bind to and inactivate these enzymes, or some dogs may use other signaling pathways besides the JAK enzyme pathway to activate the cell after cytokine (IL-31, etc.) binding.

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9. Are you checking labwork (which labs/why/how frequently?)

• No one was checking labwork.

10. In what situations are you using Cytopoint? (i.e. itch control during initial allergy workup, alternative to Apoquel, alternative to IDAT/desensitization, complementary to desensitization for itch control while desensitization has time for effect, seasonal flares, neuropathic itch, other diseases?)

• Most participants were using it in typical atopic dogs as an alternative to steroids and Apoquel.

• It was considered especially helpful in cases in which owners were worried about perceived side effects from other drugs often promulgated by online research.

• Andy Hillier cautioned against the use of Cytopoint during hypoallergenic diet trials due to the variability of duration of effect of the drug making response to a diet trial harder to interpret.

• One participant found Cytopoint was helpful to control pruritus associated with sarcoptic mange (under treatment) in 3 cases.

• Others stated it was a useful non-immunosuppressive option to control pruritus in dogs which developed neoplasia.

• Other uses mentioned included adjunctive use as pruritus control for pemphigus foliaceus (2 participants, 3 cases), erythema multiforme (1 dog), epitheliotropic lymphoma (2 participants) and calcinosis cutis (1 participant).

11. How many clients have elected to stop allergy immunotherapy and switch to Cytopoint injections as sole treatment for their atopic dogs?

• Few participants had seen this.

12. How are you pricing Cytopoint ?

• Most were using MSRP and had no issues with setting up Cytopoint in practice software.

• Kim Coyner had to set up a dual pricing structure in Impromed to acct for cost difference in small vs large dogs to match the MRSP and this made it not possible to track inventory accurately.

• Andy Hillier stated that Zoetis has designed pricing strategies for most veterinary software programs and instructions on how this can be accomplished be can obtained through your local Zoetis rep.

13. Have you administered Cytopoint to any atopic dogs with pre-existing or a history of prior immune mediated disease (i.e. vasculitis, DLE, pemphigus, drug eruption, ITP, AIHA etc.) and have there been any side effects or flare of immune mediated disease noted?

• Kim Coyner has used in in 2 pemphigus foliaceus dog and one erythema multiforme dog with good control of pruritus and no exacerbation of immune mediated disease.

• One participant had used Cytopoint on one dog with immune mediated thrombocytopenia with no issues.

• Andy Hillier stated that immune mediated issues were unlikely due to the specificity of Cytopoint to IL-31 only.

• One participant asked if yearly booster vaccinations could be given at the same time as Cytopoint and Andy Hillier stated yes, but the suggestion was made to use a different injection site.

• One participant mentioned that immunologic adverse effects have been seen with multiple mAbs in humans (Moderator note: This is correct, however there is not a direct comparison as are no IL-31 mAbs currently approved for use in humans.

A helpful summary article for human mAbs: Hansel T et al. The Safety and Side Effects of Monoclonal Antibodies. Nature Reviews Drug Discovery 2010; 9: 325-338).

The following questions were not discussed due to lack of time: 14. After the first 1-2 doses, are you having a technician administer the Cytopoint injections/no doctor exam?

15. Do some clients have difficulty bringing in the pets consistently to avoid flare if an injection is late? Do some clients elect to change to a different antipruritic medication (Apoquel/steroid/Atopica) for that reason? How often have you seen these issues occur? Are you allowing owners experienced in giving injections to purchase a Cytopoint vial and administer it to their pets at home?

REBRANDING

Did you notice that

AAVD has a new look?

2018 is the year for turning over a new leaf.

The logo and color scheme for the Academy was updated to be fresh and still maintain the tie to the caduceus.

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ROUNDTABLE SUMMARIES

Apoquel Workshop Moderator: Wayne Rosenkrantz, DVM.DVM I. INTRODUCTION a. Most attendees were familiar with the mechanism of action of oclacitinib, but a brief overview was presented in an outline format. b. Janus Kinase (JAK) enzymes are associated with cytokine receptors on the surface of cells. Can induce a variety of immune reactions. Therefore, inhibiting JAK can reduce immune responses, such as those associated with allergic reactions. c. Oclacitinib (Apoquel®) inhibits mostly JAK-1 and has minimal effect on JAK-3. At recommended dosages, there is no effect on JAK-2 or tyrosine kinase (TYK2) d. Oclacitinib’s main function is to inhibit interleukin (IL)-31. However, other cytokines (IL-2,4,6 and 13) can also be affected. e. At 0.6 mg/kg twice daily dosing the JAK-1 pathway is primarily affected. At this dosing the peak concentration of the drug comes close to impacting JAK-2 pathways. f. A series of questions and interactive discussion took place II. HOW MANY CASES HAS THE GROUP TREATED WITH OCLACITINIB? a. Variability existed amongst the attendees. Many had treated numbers in the hundreds to a few thousand, with several people also using it in limited numbers in cats. b. Initial discussion focused on its use in cats with dosing, protocols and types of conditions treated. i. Feline dosing –ranged from .6mg/kg BID to 1mg/kg BID. Most agreed that cats require higher dosing than what is seen in dogs. Most agreed that 1 month BID is typical before attempting to taper to once a day. Dr. Fadok commented on the very short half-life in cats being about 1 hr compared to 4 hours in the dog. Dr. Scolnick commented on using it TID in one cat that had been on other forms of therapy and was also a herpes virus cat and had mycoplasma on famcyclovir with no worsening of viral airway disease with reasonable control of atopic dermatitis symptoms. Dr. Rosychuk had treated a limited number of cats with 50% of the cases showing some clinical improvement. Due to the ultra-short ½ life some people mentioned considering TID dosing in cats. ii. A variety of responses had been seen with some attendees stating limited response with only a rare case responding while Dr. Cannon commenting that she had 80% response at 0.6mg/kg BID. Dr. Fadok commented on 21 cats – 18 skin disease, 2 rhinitis, 1 asthma and that these cats were placed on Apoquel as a last line of therapy. Many of the asthmatic and rhinitis cats could get off steroids and half of the cats with skin disease were able to get down their dosing reduced to once a day. Rosenkrantz commented that he has treated ~ 12 cats and using it as a last line option for therapy, using Atopica more commonly in cats. In his population of cases, 2 with eosinophilic oral granulomas had no response. It had not worked very well as a sole therapy but was a good steroid sparing agent, with most cases being able to have their steroid dosing reduced by 50%. He did have one cat that developed viral papillomas, that resolved after discontinuation of therapy. Dr. Fadok commented that no studies have been done on viral activation with Apoquel, but believes Apoquel still works on the TH2 cells more than TH1 in cats. iii. Monitoring and side effects in cats 1. Monitoring ranged from every 3 to 6 months with at least CBC/Chem/UA, similarly as done in the canine 2. Even at the high dose of 1mg/kg/BID no significant side effects had been seen in cats, other than the viral papilloma reported by Rosenkrantz.

III. HOW EFFECTIVE IS OCLACITINIB IN CONTROLLING YOUR ATOPIC DERMATITIS CASES? a. The consensus from attendees was ~ 60 -70% of the cases having good control with 20% of the cases failing to show any improvement. Many commented on the need to have patients on BID therapy, either at low dosing .3mg/kg BID or at continuous induction dosing .6mg/kg BID. Despite BID dosing even at the high dosing, no attendees felt this increased the incidence of potential side effects over recommended labeled dosing. b. Discussion regarding effectiveness for proliferative disease such as pododermatitis and otitis externa occurred. Most agreed that for scarring proliferative disorders oclacitinib was not a good choice. Comments were made regarding worsening of chronic bacterial pododermatitis or interdigital cysts in dogs on oclacitinib. c. Extensive discussion on otitis externa while on Apoquel occurred. Dr. De Bellis and others felt Apoquel to be ineffective in keeping the incidence of otitis in check while on apoquel. Some felt that the incidence of otitis was higher in the face of Apoquel. Some commented on Atopica being a better therapy for keeping ear disease in check. Rosychuk commented on higher bacteria and yeast numbers being present even if no signs of active otitis. Rosenkrantz stated in his longer-term case follow-up that there was a 14 % higher incidence of otitis in patients after being placed on apoquel, but he was unsure of these findings due to the natural course of otitis occurring in many atopic dogs controlled on a many different forms of therapy. Further discussion by the attendees on the local immune system in the ear is different than other parts of the body and that cytokine profiles likely differ in the ear than other parts of the body. d. Discussion on whether Apoquel becomes less effective over time and whether this was due to a change in disease process or did Apoquel lose its effectiveness? Most people agreed that the most common cause of failure was the development of

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pyoderma and/or Malassezia and failure to treat and control these. Others commented on the importance of maintenance of adequate flea control and ongoing topical therapy to keep microbial overgrowth or infection in check. In cases where all flare factors were well controlled it was brought up by Rosenkrantz that it may be possible that some atopic dermatitis cases could have a change in their allergy cytokine profiles with more chronic disease that IL-31 was not the only component involved in all dogs with atopic disease. Dr. Fadok went on to bring up the term “endotype”, a sub division that defines an individual’s clinical atopic dermatitis based on their specific cytokine measurements. Therefore, not all drugs will work the same for all patients and cytokine profiles likely change with time in atopic patients.

IV. WHAT IS YOUR TYPICAL INDUCTION DOSING AND TIME NEEDED FOR REMISSION? a. Many followed the recommended protocols starting at .4mg-.6mg BID x 14 days. Most do well with induction 0.4- 0.6mg/ kg BID, but many feel there is a drop in the level of control when going to SID, but feel dogs do better splitting that SID dose to BID. Others discussed shorter induction times and cutting the BID dosing to once a day pending clinical response. Dr. Cannon, Garfield and others typically start at once a day dosing at .4 -.6mg/kg and only give it BID if necessary. They feel that this once a day dosing may prevent some of the flare-ups that others report seeing when reducing from induction BID to once a day. Those on BID dosing long term typically receive more monitoring and one comment was made about a nonclinical neutropenia. Most do not see any side effects with dogs who need BID induction dosing long term. Rosenkrantz commented on adjusting am and pm dosing based on the clinical history and presentation and if more pruritic at certain times of the day you could use a higher dose at that time and lower dosing on the less severe pruritic times. The ability to taper to EOD was only rarely seen and may reflect seasonal variation, using lower frequency during times of the year when allergen levels were lower. b. Response time for immediate pruritus relief was generally seen within 1-3 days. Poor responding cases were more commonly associated with the presence or relapse of infection.

V. WHAT ARE THE MOST COMMON SIDE EFFECTS YOU SEE WITH OCLACITINIB? a. Pyoderma – Most agreed that bacterial overgrowth or pyoderma was the most common problem seen with some Malassezia relapses. Not sure how much was related to the use of oclacitinib or just the primary atopic dermatitis flaring.

However, when infection started it often was more progressive in the face of oclacitinib. Comments about skin fold, vaginal fold and pododermatitis being common sites to see pyoderma or bacterial overgrowth. b. Vomiting and diarrhea – Considered not very common, comments related to somewhere between 5-8% of cases from attendees. c. Otitis – Many attendees commented that oclacitinib treated dogs have the same incidence of otitis and that in some cases the incidence may even be higher. This was related to thought that the bacterial and yeast counts may go up in some cases while on therapy. The majority agreed that oclacitinib did not reduce inflammation or swelling in ear cases. d. Cystitis – Although reported by some to be seen in 7-10% of the cases, a recent study performed at Colorado State University (CSU), and presented at this meeting by Dr. Simpson showed no incidence. In his work, no dogs developed UTI in 55 cases while receiving oclacitinib based on follow-up urinalysis and urine culture performed during a range of 58280 days (mean 195 days) and no individuals over 6-month period (individuals had no history of cystitis). Rosychuk also mentioned one case that had a history of previous cystitis that was made worse with oclacitinib and was then switched to Cytopoint. e. Proteinuria – Seen by some attendees but incidence is low. Rosenkrantz commented that he does not routinely check UPC unless levels are 3+ or higher. He has seen some cases where the protein and UPC were elevated and in 3 cases where it dropped after oclacitinib was discontinued. Dr. Dr. Rosychuk commented that a CSU they had 3 cases with proteinuria and 1 had concurrent lymphoma. Dr. Cannon commented that in her experience the proteinuria is more common in dogs on oclacitinib for a year or longer. The incidence of proteinuria in chronic allergic dogs and those on other forms of therapies also needs to be considered when evaluating proteinuria in allergic dogs. Running UPCs in dogs with low urinary specific gravity and 2+ protein was also suggested by some attendees. No one had an answer on to why proteinuria occurred in oclacitinib treated dogs and that the clinical trials, even high dose, did not have a significant number of cases reported. f. Weight gain – Consensus is that most attendees see weight gain on oclacitinib and that it was not simply due to a reduction in pruritus. Comments on underlying mechanisms contributing to weight gain were made. It was suggested that oclacitinib may impact JAK-STAT transcription factors involved with adipocyte metabolism including insulin action, modulation of lipid stores, leptin levels, IL-6 and glucose homeostasis. In the Rosenkrantz case evaluation the average weight gain was 6.7% and in other studies it ranged from 2-10%. g. Liver enzyme elevations – Increased levels of ALP and ALT had been seen in a limited number of cases in dogs that have not had any recent topical or oral steroids. Rosenkrantz shared comments made by Ed Rosser at the WCVD 8 Apoquel workshop, stating he has seen several cases where the ALP isoenzyme elevations were noted and he was unsure why but he had ruled out Cushing’s. Since that time Rosenkrantz has measured ALP isoenzymes in 3 cases during and after Apoquel therapy was discontinued and in these cases the levels dropped significantly and all cases had Cushing’s ruled out. Cases of mild ALT elevations have also been seen. Dr. Kirby at the Marina del Rey Animal Dermatology Clinic, had 3 dogs who developed biliary mucocele felt to be related to oclacitinib use. h. Demodicosis – Many of the attendees stated that they have seen cases of demodex develop while on oclacitinib.

Rosenkrantz commented that in his case evaluation series he had an incidence of 3.4% of new cases of demodex while on

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oclacitinib. However, with the concurrent use of an Isoxazoline molecule, this has not been a big issue. With the increase use of Isoxazolines the incidence of demodex may be diminishing. Discussion occurred that demodex should be ruled out in cases when oclacitinib cases present with pyoderma. i. Neoplasia – A discussion on concerns about using oclacitinib and neoplasia development occurred. Rosenkrantz commented that the incidence reported is not any higher than what is seen in other older dogs or what is seen in predisposed breeds. Dr. Rosychuk and others agreed. Some individuals commented that in a few cases tumor development occurred shortly after starting oclacitinib. All agreed that owners and veterinarians alike will often blame such occurrences to a drug but in many cases, we cannot be sure. Rosenkrantz commented on the incidence of some round cell tumors, such as histiocytomas, being seen more commonly in oclacitinib and cyclosporine treated dogs, but this was a clinical impression. A comment that some allergic dogs that develop an emerging neoplasia have a flare of their allergy symptoms and then we often reach for more drugs to control this flare up. When drugs such as oclacitinib are selected, they may be blamed for the neoplasia when in reality it was already present. Could such drugs promote the expression of some developing neoplasia? Most commented that they would not use oclacitinib in dogs with history of known neoplasia. The impact of suppressing IL-31 remains unknown, however Fadok commented that in some forms of neoplasia, i.e. lymphoma, IL -31 may be a promotor of lymphoma and suppressing it could be helpful. Cancer development discussion with owners before using oclacitinib was brought up. Some commented that they have a brief conversation with the owner about this since it is listed as a warning on the label of oclacitinib. For owners that are concerned about neoplasia, offering other forms of therapy is given such as Cytopoint or Allergen Specific Immunotherapy (ASIT). A discussion about combining the use of ASIT with oclacitinib occurred. Many cases can be transitioned to just ASIT or can have a reduction in their oclacitinib dosing while on ASIT. j. Other rare side effects – Pneumonia was seen in an extremely rare case, and only one attendee commented about this.

Rare comments about aggression were also made but again very limited incidence.

VI. CLOSING COMMENTS a. Rosenkrantz commented on the value of having oclacitinib in our clinical practice and how it has tremendously aided in the management of canine atopic dermatitis. He thanked the attendees for all their feedback, observations and contributions to making the workshop a great success.

AAVD Executive Board

President Dr. Catherine Outerbridge Davis, CA Immediate Past-President Dr. Rod A. Rosychuk Ft. Collins, CO Vice President Dr. Leonard Jonas Wheat Ridge, CO Treasurer Dr. Klaus Loft Weymouth, MA Members-at-large Dr. Rose Miller Salt Lake City, UT

NAVDF Program Committee Dr. Mitchell Song, Chair Dr. Petra Bizikova Dr. Sandra Diaz Dr. Paulo Gomes Dr. Marci Murphy Dr. Sandra Koch Dr. Alberto Martin Cordero

NAVDF Organizing Committee Dr. Jeanne Budgin, Chair Dr. Dana Liska, Co-Chair Dr. Marcia Schwassmann, Treasurer AAVD/ACVD Dr. Christina Restrepo, Past Chair and Social/Sponsorship Liaison

Andrew Mills Shoreview, MN

Dr. Catherine Outerbridge, OC Member (AAVD)

Executive Secretary Ms. Libby Dietrich 1.877.SKINVET (754-6838) info@aavd.org

Dr. Lenny Jonas, OC Member (AAVD) Dr. Adam Patterson, OC Member (ACVD Dr. Allison Kirby, OC Member (ACVD)

Welcome New AAVD Members!

ECVD Members Flavia Santos, DVM, MSc ESVD Members Gonzalo Pinillos, DVM Student Award Members Christopher Alling, DVM Samee Berger, DVM Scott Bertoldo, DVM Ashley Day, DVM Katrina Frost, DVM Karly Hicks, DVM Kelsey Lawrence, DVM Taylor Morrison, DVM Veterinarian Members Daehee Cho, DVM, MS Aurrielle Eberhardy, DVM Sarah Morar, DVM Amy Schnedeker, DVM, MS Wendy Terry, DVM Affiliate Members Daniel Keularts

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Veterinary Technicians in Veterinary Dermatology Moderator: Jon Plant, DVM Both board-certified veterinary dermatologists and veterinary technicians were well represented. A dermatology resident and general practice veterinarian were also in attendance.

Utilization of Veterinary Technicians: the skills of vet techs enable veterinary dermatologists to work more efficiently. The ratio of veterinary technicians to dermatologists among the group ranged from 1:1 to 2:1.

Participants noted that vet techs are used in their practices to verify items on the history form that a client has filled out, take samples for skin and ear cytology, fill prescriptions, go over estimates and invoices, draw blood, monitor anesthesia, refine scheduling to the needs of a particular patient or procedure, educate clients regarding treatments, and to serve as a point of contact for clients.

Some participants rely on vet techs to interpret skin and ear cytology samples; many vet derms interpret cytology themselves.

One noted that she had created a visual aid to assist vet techs in interpretation. Another noted a recently published reference “Canine and Feline Skin Cytology” by Albanese.

Most veterinary dermatologists utilize veterinary technicians or assistants to perform intradermal testing, but choose to interpret and assign subjective scores themselves. Some busy practices have veterinary technicians whose primary job task is to fill allergenic extract prescriptions. Most of the participants agreed that they would not feel comfortable training vet techs to perform ear flushes with video otoscopy due to the steep learning curve.

Recruiting, hiring, and retention: several participants pointed to attractive features of being a vet tech in a dermatology practice as recruiting or retention incentives. These included interacting with other departments (in an academic setting), having a steady routine, establishing long-term relationships with clients and pets, and little or no participation in euthanasia. When travel is involved in working in satellite locations, this can negatively influence retention.

Recruiting sources that were mentioned included online listings (e.g. Craigslist), tips from distributor reps, and postings at vet tech schools. One large hospital employed a full-time recruiter. Staffing part-time locations was mentioned as a challenge for attracting applicants.

Financial incentives such as signing bonuses and quarterly bonuses were mentioned as retention tools.

Training: the veterinary technicians in attendance agreed that the primary motivation for pursuing certified Veterinary Dermatology Technician training would be personal enrichment. One participant takes time to discuss diseases with her vet techs during slower times. Others present more formal continuing education to vet techs.

Microbiomes Moderator: Alison Diesel. DVM The cutaneous microbiome is an area of human and veterinary dermatology that has been gaining a lot of attention over the past few years. The roundtable began with a review of relevant terminology often seen in microbiome literature: • Microbiome - all microbes in a habitat, their genes and metabolites • Microbiota - Collection of micro-organisms in a defined microenvironment; characterization often based on conserved genes found on bacteria (16S rRNA) or fungi (18S rRNA, 28S rRNA, ITS (internal transcribed) regions) • Mycobiome - fungal organisms in a microenvironment • Virome - viral communities in a sample -- lack conserved regions in genome (smaller viral database currently available) Two graduate students from Texas A&M University whose PhD thesis work involve the cutaneous microbiome and mycobiome in dogs and cats were in attendance. They discussed the process of next generation sequencing (NGS) and sample collection. NGS is similar to PCR in that it amplifies sequences according to primer detection based off of what sort of organisms are being evaluated (e.g. 16S rRNA for bacteria and 18S rRNA/ITS for fungi); however, compared to older PCR studies that read the most abundant DNA sequences in a sample, NGS reads ALL of the sequences present, thereby creating an enormous data set identifying hundreds of thousands of organisms. The data set is then evaluated in terms of diversity analysis. This is a process of evaluation initially created for ecology studies, however it has been adapted for microbiome studies in the past few years. Samples are generally analyzed in terms of their alpha and beta diversity; alpha diversity is determined by the number of species present in a sample, whereas beta diversity is determined by which particular species are actually present.

Discussion then focused on what is known thus far in regards to the cutaneous microbiome. Much of the current literature is rather descriptive in nature, highlighting differences in populations of organisms in the face of health and disease. Additionally,

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this is still a very new area of focused research; only a dozen or so manuscripts have been published in the veterinary literature, however much more is known in people. Due to the current limitations of cost for sample processing (approximately $65 at best for sequencing of each individual sample; in an individual animal, generally 6-10+ body sites are sampled), these studies generally involve only a small number of animals per group. Most studies are based off of approximately 20 animals or so, however larger studies are underway. Based on these publications however, a few key points can be noted: there have been large numbers of organisms isolated on the skin of dogs and cats, many more than what had been reported in older culture-based studies. The most commonly found bacterial organisms belong to the phyla of Firmicutes, Actinobacteria, and Bacteriodetes. In dogs and cats with allergic skin disease, Staphylococcus is found much more readily than from animals without dermatological abnormalities.

Some newer longitudinal studies are underway attempting to evaluate how the microbiome changes over time; one such study

by Thierry Olivry et al for example has looked at the microbiome in relation to lesions associated with atopic dermatitis and how these are altered in various states of disease. What is a bit less certain is how stable the microbiome is in dogs and cats without dermatological abnormalities; what “normal” variations may occur over the life of a patient is not yet certain. There are studies that have identified changes in broad age ranges (e.g. identifying differences in bacterial populations on the skin of neonates compared to adults), however there is not yet information in how a specific microbial population is altered over time in a certain individual. Other studies have looked at geographical differences in the microbiome across species; while there is much more variability in people based on location character (e.g. sebaceous vs. dry skin regions), there is less variability seen in dogs and cats; mucosal surfaces, however, compared to haired skin does show difference in microbial population characteristics. Additionally, studies are underway to evaluate microbiome differences based on breed.

From here, future foci and research directions were discussed. Several people were interested in whether these microbiome studies not only evaluate the bacterial species, but whether organism resistance is also present (e.g. whether mecA gene encoding methicillin resistance in Staphylococci can be identified); this sort of study would require more of a metagenomics evaluation to determine what is truly present. This has not yet been pursued in veterinary species, however it is in the early stages of evaluation in human medicine. Other interests include the connection between the cutaneous and gastrointestinal microbiome, and whether grooming habits can influence these particular populations; a group at UC Davis is beginning to evaluate this relationship. Many members were most curious about how this microbiome information will influence treatment recommendations, and how particular therapeutics can alter the cutaneous microbiome in our patients. Of particular interest, topical therapy, including antiseptic bathing and those products containing silver, were of interest for evaluation. The immune status of the host was also of interest; while a few diseases have been evaluated for their influence on manipulation of the “normal” cutaneous microbiome (e.g. allergic skin disease), other disease states would be interesting to evaluate. Lastly, the discussion of not only what is on the skin, but what is it doing/how is it functioning was addresses. Metabolomic studies are in their infancy in regards to the gastrointestinal microbiome, establishing connections between the host environment and the organisms able to survive and function; these studies will need to be performed for the cutaneous microbiome in order to assess whether organisms are being influenced by the state of the host, or whether the microbiome organisms themselves are rather driving the disease state. While we are starting to gather meaningful and interesting data in the world of cutaneous microbiome research, there is much yet to be learned and to determine whether we can use this information for therapeutic advances in veterinary (and human) patients with dermatological disease.

Perianal and Perineal Dermatitis Moderator: Katherine Doerr, DVM. Dipl. ACVD Perianal fistulas Differential diagnoses: cutaneous adverse food reaction, ruptured anal glands, neoplasia, concurrent IBD/colitis (seen concurrently on scoping by some individuals) Favorite diets for management – Prescription kangaroo, Purina H/A (especially if concurrent GI signs) Therapeutic options – Most individuals started with Atopica® (name brand) 5-7mg/kg q 24hr as decreased efficacy seen with generic versions. Once fistulae are controlled, many add topical tacrolimus in order to taper the Atopica®. Oral corticosteroid is used by some if patient is extremely painful. If non-responsive to corticosteroids and Atopica®, suggestions included oclacitinib or mycophenolate (unknown efficacy).

Mucocutaneous lupus erythematosus Differential diagnoses: mucocutaneous pyoderma (MCP), urine leakage Diagnosis: most via clinical suspicion and ruling out MCP, occasional via biopsy Therapeutic options: doxycycline/niacinamide vs Atopica® - topical options: tacrolimus (www.canadadrugsonline.com or compounded at Diamondback), triamcinolone, sucralfate/ Aquaphor® (1 tablet in 2oz Aquaphor®), cicalfate

ROUNDTABLE SUMMARIES

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- E-collar, men’s boxer-briefs have been used after applying topicals Other thoughts: - should there be more work-ups for allergies/treating for allergies?

- Should there be more urinalysis or urine cultures performed?

Anal sacculitis - Is it best to remove them if it is a recurrent issue? Some say “yes,” if it a source of constant pruritus/discomfort for patient; however, important to rule out any potential allergic problem initially. Anal sacculectomy has inherent risk such as fecal incontinence.

- Rule out cutaneous adverse food reaction 100%- some perform 2nd diet trials - Therapeutic options: Flush with dilute chlorhexidine, infuse anal sac (Panalog®, Otomax®, etc.)

- If deep pyoderma- oral antibiotics (i.e. amoxicillin/clavulanic acid, fluoroquinolones) Allergy Diagnosis: Cutaneous adverse food reaction vs atopic dermatitis vs flea bite hypersensitivity. Prevalence amongst group appeared to be well-distributed (i.e. each ddx seen in equal frequency).

- Therapeutic options: - Bichons with preputial pruritus seem to respond to gabapentin (up to 20 mg/kg) up to TID. - When atopic dermatitis is diagnosed, does allergen specific immunotherapy seems to be a viable option for localized pruritus in this area? Not really--other parts of the body may respond, but in the group, many dogs continued to be pruritic in the perianal/perineal region.

- This maybe due to increased contact exposure to grass/ less hair/ increased glandular secretions in that area Stud tail - Diagnosis: Intact males. If castrated- check adrenal glands/hyperadrenocorticism; secondary pyoderma - Therapeutic options: Topical antimicrobials, Douxo® Seborrhea Spot-On vs Dermoscent® (either one- Douxo® Seborrhea has less of an odor) Perianal/ Hepatoid tumors - Most seen in intact male dogs- Castration may result in remission - Associated with hyperadrenocorticism in neutered dogs?

- Anal sac mass/small nodule - DDX: Inspissated material, anal sacculitis, anal sac adenoma/adenocarcinoma - Some aspirated suspected anal sac masses while other were concerned for tracking/contamination of the tissue with that method.

- Other work-up option included abdominal ultrasound and bloodwork (check for hypercalcemia).

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ROUNDTABLE SUMMARIES

Probiotics Round Table #12 Moderator: Rebecca Mount. DVM. • The majority of participates were not regularly using probiotics at this time. Some participants mentioned anecdotal success using it in well controlled allergy cases that still struggled with recurrent pyodermas. The participants utilizing probiotics tended to see improvement within a couple weeks, but again this information was all anecdotal.

• The most common use of probiotics amongst the participants was for improved tolerance of antibiotics. Some participants start it concurrently with antibiotic use, while others recommended it if the patient is having GI side effects from the antibiotics. Other clinicians recommend it only when clients voice concerns about potential GI upset and antibiotic use.

• Several studies on probiotics were discussed. The majority of participants were most familiar with the Marcella, R. paper Evaluation of Lactobacillus rhamnosus strain GG for the prevention of atopic dermatitis in dogs (Am J Vet Res. 2009 Jun;70(6):735740. The group discussed that there is lack of strong evidence supporting the benefits of probiotics. The main questions that lack scientific evidence is the ideal time to utilize probiotics, the ideal dosing, and ideal strains. However, most participants agreed that probiotics are unlikely to have any major negative side effects.

• One participant has recently completed a study on the effects of probiotics on atopic dogs over a 3-month period in Japan and noted positive outcomes. Ideally this paper will be published soon.

• There was brief discussion about the potential use of probiotics in the cases of canine adverse food reactions. One participant prefers Proviable (Nutramax) because it contains 7 different strains of probiotic microorganisms.

• There was a brief review on the definition of probiotics. The strain Lactobacillus rhamnosus GG is the most frequently studied probiotic in human and veterinary medicine. It is thought to decrease intestinal pH and suppress harmful proteolytic bacteria.

• Probiotics should ideally be isolated from the same species as intended by the host. This lead to a discussion on the types of products available. Many people are using Culturelle (i-Health, inc) which is a human product containing Lactobacillus GG. Most participants that are using it dose it at one prepackaged envelope per dog once daily. This product was preferred because of cost and availability. Veterinary products that were discussed included: • FortiFlora (Purina) which contains Enterococcus faecium • Contains hydrolyze pork and beef (animal digest) • Participants do not use during food trials • Prostera (previously Iams, off the market)-bifidobacterium animals AHC7 • Proviable (Nutramax) the powder contains 7 stains: • Enterococcus faecium • Streptococcus thermophilus • Lactobacillus acidophilus • Lactobacillus bulgaricus • Lactobacillus casei • Bifidobacterium bifidum • Lactobacillus plantarum • Proviable (Nutramax) paste: Labelled for acute diarrhea and contains beef flavoring • ProGut Plus (Ceva): Is currently not available in the USA. It is a vegan product and contains probiotics, prebiotics, clay, beta glucans, and digestive enzymes.

• It was discussed that if human products are not working it may be beneficial to switch to a veterinary formulated product.

• The group discussed additional human products as well as yogurt as sources for probiotics. The group agreed that yogurt as a probiotic source was impractical as the amount of yogurt needed to provide an adequate amount of colony forming units (CFU) was excessive. VSL 3 was mentioned as it had been recommended by Dr. Joeseph Bartges, DVM, DACVN because it has the highest CFU and consistently met it’s labelled claims. The participants discussed the drawbacks of this product including: the expensive and the fact that it is a human product.

• The lack of regulation of probiotics by the FDA was discussed. The 2011 paper by JS Weese was cited (Can Vet J. 2011 Jan; 52(1):43-46. This paper evaluated 25 probiotic products. 2125 products listed specific organisms. Only 2 of these products had an acceptable label, which properly described the contents and only 4/15 products that had specific claims met or exceeded their label claim.

• The participants discussed the appropriate timing for dosing probiotics. One participant had been previously taught that antibiotics and probiotic should be separated by at least 3 hours to prevent deactivation of the probiotics by the antibiotic.

The Japanese study used heat killed strains and timing of dosing did not matter. Appropriate dosing recommendations are uncertain at this time.

• There as a brief discussion amongst participants about prebiotics. A prebiotic is an ingredient that promotes the growth of

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beneficial microorganisms (aka probiotics) in the intestines. Most participants felt that this was important to combine with probiotic use. Ideal products would combine both pre and probiotics.

• The participants that were utilizing probiotics in cats were most commonly using Fortiflora. They felt there was more supportive research with this product in cats and the powder form was easy to add to the food and it seemed palatable to most cats.

• Finally all participants agreed that with the growing interest in the microbiome, probiotics may play a larger role in the future.

Otitis Roundtable Moderator: Andrew Rosenberg DVM, DACVD -Attendance was taken -Rules of roundtable discussed; meant to be a participatory discussion -Sponsor: Royal Canin First discussion point was Claro vs. Osurnia – who is using what and what has their experiences been?

Dr. Gortel: uses Osurnia for compliance; not for severe cases; hasn’t tried with rod infections; saline to flush prior to instillation; Dr. Eisenschenk: uses Epiotic flush prior; reapply in 1wk; recheck cytology and otoscopic exam Mesman: uses both products but uses Claro more. Has had minimal success with yeast otitis Dr. Ganz: uses Claro more since longer acting; flushes prior to initial application but not before reapplication. She does not use if significant debris is present Dr. Mesman: Uses both products based on cytology and Culture and Sensitivity Dr. De Billis: uses mainly Osurnia. He has not used it in dogs with ruptured ear tympanums but does get questions regarding its use with ruptured tympanums . He does see primary veterinarians using it in difficult patients; He has had minimal success with yeast otitis.

Dr. Sadeghi: minimal use; has not had any good results; He does have success using burrows solution (for new cases); should we stop using antibiotic in ears as first option?

Dr. Rosychuk: using antibiotics inappropriately is a huge problem; it’s a problem that most commercially available products have antibiotic, antifungal and steroid; instead he prefers to formulate medications in house Dr. Rosenberg: Osurnia will be labeled for pseudomonas in brazil; In the Brazil studies mixed infections with Pseudomonas was cleared but Pseudomonas only cases did not. What does everyone think about Pseudomonas and Osurnia?

Dr. Botelho: Osurnia or Claro are not yet available in Brazil Dr. Eisenschenk: Bacterial difference in different regions; dangerous to say drug will work everywhere (especially Pseudomonas) Dr. Botelho: she sees mostly staph in brazil; Rarely sees Pseudomonas.

The group was polled on who uses Claro only vs. Osurnia only vs. neither vs. both. The group was split relatively evenly with approximately 25% of participants in each category.

Dr. Eisenschenk: prefers these products compared with the lanolin based leave-in products Dr. Klenofsky: There is a long residual effect with Osurnia even though labeled for repeat dose after one week Dr. Ganz: She uses lanolin based products frequently. She uses BCP compounding pharmacy and likes their products because they will compound the paste with any antibiotic based on culture results; The problem is time getting the product made and shipped to the owner and then having the owner come in for application Second Discussion Point: Who is making in house ear medications? What are you making? Are you sharing recipes with primary veterinarians?

Dr. Rosychuk: Combination of miconazole/dexamethasone is what he uses most commonly and mixes it in a 1:1 ratio; He uses lotion vs spray miconazole Dr. Jeromin: she compounds a lot; does not like that there is gentamicin in every product. She will make her own ear medications with the following antibiotics: ciprofloxacin, amikacin, baytril/synotic; miconazole/synotic. She is concerned about compounding pharmacies not studying stability. She does share recipes but says disclaimer Dr. Rosenberg: Will you use last line drugs in ears?

Dr. De Billis: In his country they are very cautious with antibiotics; He will use SSD with triz +/- baytril; will share recipe Dr. Gortel: Shares recipe (on referral letter)

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ROUNDTABLE SUMMARIES

Dr. Eisenschenk: Believes recipe should be part of medical record Dr. Ganz: Primary DVM records often state otic drops but do not list ingredients Dr. Mesman: Will share recipes, but has concerns when recipes for antibiotic preparations are given and primary veterinarian is not performing cytologies to ensure appropriate use. At a hospital she visited was told they don’t do cytologies Dr. Ganz: A friend of hers who is a primary vet was told not to do cytologies by her boss because it takes too much time Dr. De Billis: Primary veterinarian should be using products on shelf vs asking us for recipes to ensure appropriate use Dr. Rosenberg: If primary vet calls and asks for recipe for amikacin ear drop based on culture when that it the only antibiotic that the bacteria are sensitive to, what should we do if last choice antibiotic – give out recipe or recommend referral because this is last choice antibiotic?

Dr. Eisenschenk: will talk to primary veterinarian about referring pet and will try to impress upon vet that this is our last option Dr. Carnett: Frequently makes N-acetylcysteine in office and has had very good success. Good results with exudative ears and with rods. Will mix N-acetylcysteine with t8 keto flush; stores in fridge for stability; Mixes it in a 1:9 dilution; Dr. Foust: has had a compounding pharmacy make N-acetylcysteine drops it and was only stable in fridge x 2 weeks; Compounded drops were pricey and N-acetylcysteine can be bought for low cost on internet; Has had good results with mixed bacteria; has used with antibiotics (but in separate prep).

Dr. Carnett: Will typically use the preparation for 1 month Dr. Rosenberg: Any ototoxicity concerns?

Dr. Carnett: Studies have shown that as long as you stay below 2% then it should not be ototoxic Dr. De Billis: Uses N-acetylcysteine orally in cavaliers’ dogs with PSOM Discussion followed about infusing N-acetylcysteine into dogs with PSOM following myringotomy and if there is any ototoxicity concern. Some of the participants do use it will infuse canal after video otoscopy; no one has had any ototoxicity issues. Some participants will dilute it, while others will use it straight out of the bottle.

Discussion Point Three: what other alternative ear products is everyone using? Is anyone using the VetBiotek Ultra-Otic Concentrate (microionized silver) or there was a paper that showed medical grade honey could be helpful for otitis. Has anyone used honey in patient’s ears?

Dr. Everett: Has used the silver product on an employee’s pet and one client. Did not think it was very helpful and can stain clothing.

Dr. Jeromin – has had the silver product become gelatinous Dr. Everett: finds it hard to get the VetBiotek product out of the pipette. Has had poor results with staph. Has not been impressed so far.

Dr. Ganz: One doctor in her practice does use the Ultra-Otic frequently and has had success using it in chronic ears Dr. Rosenberg: What about medical grade honey?

The American College of Veterinary Dermatology recognizes and thanks

Dr. Ganz: She did have one owner who had tried to use manuka honey in a pseudomonas ear. She saw the pet and both pus and honey poured out of the ear and the honey was not helpful.

The American Academy of Veterinary Dermatology

No one in the group was recommending honey to their clients for the treatment of otitis.

as a 2017

Dr. De Billis: Does like to use silver sulfadiazine with triz +/- baytril Dr. Carnett: Has anyone used cameo? He is not sure what active ingredients are in but he has used in malassezia.

Not sure if it is still available.

Principal Sponsor of the ACVD Research Foundation

The participants overall did not use Cameo and the few that did had not had very promising results.

The discussion went on to Pseudomonas with participants asking the following questions: Who routinely flushes pseudomonas as a first-line option? One participant

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thought that many cases may resolve without flushing at all as long as steroids are used Dr. Rosenberg: My protocol for pseudomonas is: cytology, culture if suspect Pseudomonas, and then put them on 1mg/kg/day of medrol, flush with triz/edta until culture results. The topical antibiotic is chosen based on culture and recheck in 2 weeks. If still seeing large amounts of bacteria or debris at recheck I typically recommend video otoscopy with deep flushing.

Dr. Gortel: Difficult to flush when ears are so swollen.

Dr. Rosenberg: I typically find that dogs have to be on a good dose of steroids to have a successful flush Two participants think a high percentage of ears will get better without flushing and with just high dose of oral steroids.

Dr. Rosychuk: Steroids are a huge part of treating Pseudomonas. Thinks video otoscopy will fail if steroid is dosed too low.

Dr. Gortel: Are products being used once daily vs. twice daily? Are products being dosed on labeled recommendations (drops) vs. volume (ml).

Dr. Ganz: doses on volume and give owners syringes: 0.3 for little dogs and 0.5 for large dogs Dr. Rosenberg: used 0.5 and 1ml. Dr. Noxon has done work showing that drops that most products are labeled for is not enough to coat ear canals.

Dr. Foust: will uses syringes and will recommend up to 2.0 ml for Basset hounds, 1.0 ml for other large dogs like Labradors Dr. Ganz: Prefers volume because owners can’t count drops when instilling Foust: stays away from ointments Dr. Foust: asked group their thoughts on treating yeast otitis with miconazole. Will typically recheck weeks after starting on miconazole/dex ear drops and seeing more Malassezia organisms than expected. Thought it may be due to compliance issue but now seeing it with her own dog.

Dr. Mesman: has seen refractory yeast otitis Dr. Rosychuk: Topical steroids are helpful for yeast and speeds resolution (good success in 2-3wk). May think about increasing concentration of dexamethasone in ear medication Dr. De Billis: In these care is it yeast overgrowth or true infection with neutrophils too? Thinks steroids and oral antifungals helpful; has had a few cases that needs to be treated for long term and has found oral itraconazole helpful.

Dr. Rosenberg: will add a crushed up ketoconazole tablet in miconazole/dex ear solution and has had success in cases of persistent Malassezia otitis after using miconazole/dex Dr. Rosychuk: also helpful to make more acidic (1 part vinegar 2 parts water) for yeast otitis. He definitely is seeing resistant yeast.

Dr. De Billis: Thinks malacetic is helpful for yeast otitis Dr. Gortel: Anyone using miconazole for Staph?

Dr. Rosychuk: Is not, as it only has low grade staph effectiveness Dr. Rosenberg: Miconazole synergistic with chlorhexidine. But without chlorhexidine not great for staph bacteria. When using miconazole/dex ear drops will sometime see the yeast resolve but can then see staph otitis. There has been some discussion about “ghost yeast.” Are these the resistant yeast?

Dr. Rosychuk - yes there are resistant yeast but not the “ghost yeast” Dr. Rosenberg: When seeing resistant yeast is there resistance to all azoles?

Dr. Rosychuk: not all azoles, changing azole will usually resolve Dr. De Billis: Could the resistance be due to something else? Ketoconazole should be given with food (maybe fatty meal). If the owner is giving on an empty stomach could this be contributing to resistance? Again, he likes to use oral antifungals for some cases of yeast otitis Dr. Jeromin: Discussed the use of oral antifungals Dr. Ganz: Possibly addition of oral antifungal vs. just need more time on topical therapies Dr. Jeromin: Do we think that the azoles penetrate the ear?

Dr. De Billis: There is a paper out on itraconazole twice weekly and after 4wks there was improvement Dr. Diamond: Has had good success using Zymox HC for yeast otitis as first line therapy (even with purulent debris) Other participants have not had good success with Zymox. Many participants will see patients come in as an initial consult on Zymox and will recommend stopping it.

Dr. Rosenberg: - Is anyone aware of any controlled studies on Zymox?

No participant was aware of any studies at all on Zymox.

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Behavioral Dermatoses Moderator: Stephanie Borns-Weil, DVM The discussion was started with the general question to participants “What issues do you face diagnosing and treating problems that may be behavioral in your veterinary practice?”

1. The 2006 paper “Underlying medical conditions in cats with presumptive psychogenic alopecia” by Waisglass, Landsberg, Yager, and Hall was summarized. The authors found that medical causes of pruritus were found in all but 2 cats. An additional 3 cats were found to have both medical causes of pruritus and psychogenic alopecia. The other cats were found to have atopy and/or food intolerances. The authors also found that all the cats with histological evidence of inflammation were found to have medical causes of pruritus. However, of 6 cats with no histologic evidence of inflammation, 4 were found to have atopy and/or food intolerances and 2 were found to have psychogenic alopecia.

2. A question was raised about how to proceed with treating cats that continue to barber once atopy and food allergies were ruled out or treated.

-A point was made about the need to pursue diagnoses more aggressively before assuming that the problem of barbering is psychogenic.

-A discussion took place about how much diagnostics are enough before assuming psychogenic alopecia and about how to find a balance that takes the limited means of pet owners into consideration.

-The moderator made the point that, from a practical point of view, it may not be necessary to withhold treatment for psychogenic alopecia until every other diagnosis is ruled out since the behavioral aspect of the treatment which consists of environmental enrichment and addressing causes of stress in the cat’s environment, will not cause harm and will likely improve an indoor cat’s quality of life regardless of whether a diagnosis of psychogenic alopecia is finally made. Furthermore, because a link between stress and allergic dermatitis has been made in the human field of psychoneuroimmunodermatology, treatments designed to reduce stress in pruritic cats may have benefit.

-The moderator also made the point that SSRI medications, which are the current gold standard for treating compulsive behaviors in cats and dogs can be also be tried before all medical causes of pruritus have been ruled out. SSRIs are generally well tolerated in cats and are relatively safe in otherwise healthy animals. She noted that a failure to respond to medication does not preclude a diagnosis of psychogenic alopecia, though a complete resolution of the alopecia does rule out pruritus.

3. There was a brief discussion of whether complete resolution following corticosteroid trial precludes a diagnosis of psychogenic alopecia. The moderator believed that psychogenic alopecia could be ruled out by a corticosteroid trial because corticosteroids will not affect compulsive behaviors.

4. There was a discussion of the categories of behavioral dermatoses in human medicine as applied to veterinary medicine in Dr. Vint Virga’s 2004 article “Behavioral Dermatology” in Veterinary Clinics of North America, Small Animal Practice. His category “Primary behavioral disorders” includes acral lick dermatitis in dogs, psychogenic alopecia in cats, self-directed attention-seeking behaviors and psychogenic pruritus. His category “Secondary behavioral diagnoses” includes pruritus that impairs an animal’s ability to function in its social group. His third category “Cutaneous sensory disorders” includes feline hyperesthesia syndrome.

5. There was a discussion of the primary causes of stress for indoor cats. Roundtable participants raised lack of stimulation, lack of human companionship and extended solitude as well as intercat household aggression as common causes of stress in cats.

The moderator added that intercat household aggression is very common in multicat households and often goes unnoticed by owners if there is no active fighting. She also mentioned that in her clinical experience, a stressor always triggers psychogenic alopecia.

6. Pharmacologic options for the treatment of canine acral lick dermatitis were discussed. Most participants stated that they were taught that doxepin was the best option because has antihistaminic properties as well as serotonin reuptake inhibition.

The moderator raised stated that she does not use doxepin as a first line treatment for acral lick dermatitis because acral lick dermatitis is a compulsive disorder, which is not pruritic or allergic in nature. The dominant opinion as expressed in the medical and veterinary literature is that serotonin reuptake inhibition is that serotonin reuptake inhibitors are the most effective pharmacologic treatments for compulsive behaviors. Doxepin has strong norepinephrine reuptake inhibition but only weak serotonin reuptake inhibition. Therefore a better choice is a selective serotonin reuptake inhibitor like fluoxetine. Clomipramine can also be effective because although it has some norepinephrine reuptake inhibition, it has very strong serotonin reuptake inhibition as well.

7. One of the participants shared her experiences with the use of acupuncture in the treatment of psychogenic alopecia.

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Skin Barrier Roundtable Moderator: Jason Bradley, DVM The roundtable was attended by boarded dermatologists, residents, technicians, and corporate representatives.

Originally we discussed which topical therapies are used commonly to help improve skin barriers. Some have had experiences with patients that a “less is more” approach for bathing may be more beneficial due to worsening of clinical signs afterwards. In those cases, human eczema products are even used which worsen clinical signs in some of those patients. Most of the attendees agreed that there is a small subset of those patients which worsen with topical treatments, but many patients benefit from topical shampoos on a regular basis. Several attendees recommend 2-3 minute contact time for shampoos. Numerous other people typically recommend 10 minute contact time, with hopes that they achieve 2-3 minutes. One attendee recommends lathering up the dog well and taking it for a 5-10 minute walk prior to rinsing it off. It was stated that we could definitely increase compliance if we were offering bathing in our clinics, but no attendees currently bath animals on a regular basis due to space and time consumption. In order to increase compliance for bathing with prescription shampoos, it was mentioned to dispense multiple bottles in cases that are groomed regularly while asking the groomer to keep one bottle at their shop.

The topic was shifted to topical moisturizing products and which products are commonly used with the most success. Several attendees really like the Dermoscent ® Essential 6 spot-on. Unfortunately, one attendee had another dog attack their housemate when that product was applied. Several others have had some cats with contact reactions to this product. Others tend to like the Douxo ® Seborrhea Spot on product, especially due to the fact that it is odorless. There are relatively few people who use cream rinses or lotions on a regular basis. One product that several people liked was the 1% hydrocortisone leave on conditioner which is currently made by VetBiotek under the Vetergen label. Another attendee uses a 1:1 ratio of water and baby oil as a pour on rinse for 20-30 minutes prior to rinsing. She will also use a 1:1 ratio of water and propylene glycol in the same way, but has had a small number of patients become more pruritic. Another attendee uses 1 tbsp of baby oil in 1 gallon of water and sprays this onto the coat.

Performing whirlpool therapy has been shown to be beneficial in cases of resistant pyodermas, but nobody uses this commonly for atopic dermatitis. There are also some patients where the atopic dermatitis is much better controlled when they are swimming in a chlorinated pool on a regular basis. A few other attendees have also had a similar result, but they have also had some developed a rash to the chlorine. One attendee has also seen improvement of patients when they use salt water pools as that is becoming more popular in the northeast region of the United States. Another attendee agreed with the improvement of his dogs that swim in the ocean, but stated again they should be rinsed off afterwards. One attendee is firmly a believer in salt water soaks as he has horrible eczema and it greatly improved after soaking in the Dead Sea daily for 2 straight days.

Fatty acids and fish oils were discussed next in regards to types of supplements and personal experience. Some will give very direct guidelines to the amount of EPA and DHA to purchase over the counter. There was complete agreement that coconut oil is one of the new fads out there. Several attendees feel that the best fish oil supplements are in the diet, which have high amounts and are highly bioavailable. Examples of those included Hill’s Derm Defense, Royal Canin Skin Support, and Hill’s J/D. You can’t really compare one diet to another though since they don’t disclose the exact amount in each diet. One attendee is using a newer product by Veterinarian Recommended Solutions and has liked it so far. Free form snip tips were commonly used with a few other attendees. Cats are difficult for fatty acids and fish oils due to them not liking topical products and difficulty getting them to take oral fish oil products at times. The diet can be highly beneficial in these cases and Hill’s Sensitive Skin and Royal Canin Skin Support are options. Some attendees have seen some improvement in quite a decent number of dogs with atopic dermatitis when using the Hill’s Derm Defense or Royal Canin Skin Support for a minimum of 6 weeks prior to the seasonal flare time.

Pododermatitis can be a common problem with atopic dogs and some people have been using the Douxo ® Seborrhea Spot on and Dermoscent ® Essential 6 divided among the paws affected. They have had good success with this treatment in decreasing the pruritus and erythema.

TECHS

AAVD continues to provide support to the Academy of Dermatology Veterinary Technicians (ADVT) as they establish themselves as an active body.

Techs can now visit www.vetdermtech.com to find credentialing packets for submission.

Currently, 22 techs are working toward being credentialed by ADVT. The inaugural VTS (Dermatology) exam happened at the 2017 NAVDF. The next exam will be administered at NAVDF in Maui. AAVD looks forward to the continued success of ADVT and is thrilled to support technicians as they work toward this credential.

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ROUNDTABLE SUMMARIES

NAVDF 2019

April 10-13 HILTON AUSTIN

ANNOUNCEMENT

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